Two managers talk to Maura Thompson about the challenges they face to improve services and keep up with demand

John Parker, 39, is commissioning business manager, North and East Devon health authority Salary:£35,000

Describe your current job

To be quite honest I am still learning about my job. I have been in post for about nine months and every day brings a new set of challenges. The main elements are commissioning specialist services on behalf of the health authority, supporting primary care groups in their commissioning role, performance management, service improvement and the modernisation agenda. I am the project manager for the community-wide booked admissions programme, working with local trusts to improve patient access to day cases.

What was your career path?

I first worked as a computer programmer for a local authority in the days when computers were worth more than staff. Frustration with the lonely life led to a move to London to study sociology and communication. After studying I worked for a social services department developing residential and daycare facilities. Having seen where the real money was, I joined Waltham Forest health authority in 1987 as capital programme manager. In the purchaser-provider split I chose the provider side and in total worked in Waltham Forest for 13 years. I was supported by Forest Healthcare trust in studying for a master's degree in health facility planning at London's South Bank University, while working full-time on developments at Whipps Cross Hospital.

The combination of analytical, service and facility planning skills brought me to a key role in contracting and service and financial framework discussions along with performance management to deliver national objectives. I learned a good deal about acute services, patient flows and service management and worked with many people for whom I have the utmost respect for their dedication to health services.

What attracted you to this job?

There were many attractions. The move into Devon and the chance for a new start in a relatively successful health community in a beautiful part of the country spring immediately to mind.

How many people work in your team?

There are about 15 key people in the HA, primary care groups and local trusts.

How many hours a week do you work?

I spend about 45 hours a week at work and often read papers or browse the Internet at home. I think that it is important, particularly as a single parent, to balance work and home life.

What is the most satisfying part of your work? I do not yet have any real sense of satisfaction - there is far too much to do and learn. I consider it a privilege to work in the health service and to make a small contribution to health improvement.

What is the most frustrating thing about your job?

It has ever-shortening, never-ending deadlines. Health services are under-managed; this is the main threat to delivering the change agenda.

What is the biggest challenge you face in the coming year?

The challenge has been laid down by the government to modernise. In almost 14 years of my health service experience the challenge has been to provide more for less. I have said many times and believed that changes could and should be made to increase the efficiency of services and reduce costs. The potential for change with the assistance of additional resources is almost scary.

Fitting modernisation into a commissioning and performance management framework that benefits the health community and satisfies the NHS Executive is my challenge.

How do you relax?

My ideal evening after work is a game of tennis, a hot bath and a good TV programme.

What has been the high point of your career?

I have a really good feeling that the high point has not yet been reached. But up to now, for the sense of real achievement, my input to a major redevelopment phase of Whipps Cross Hospital from inception to opening - helping turn an empty shell of a new building into state-of-the-art patient facilities - has to be it.

If you had chosen an alternative career, what would it have been?

My alternative career would probably have been in information technology.

Where do you see yourself in five years?

I am not particularly ambitious in terms of money or power. I feel confident that the modernisation agenda is here to stay and that my skill set and experience will allow me to choose a very satisfying role.

John Towers, 40, is integrated care team leader with Brighton Health Care trust Salary:£31,000

Describe your current job

My role is about challenging traditional thinking. I lead a team that helps operational staff redesign services to make them more patient-focused. This involves managing a range of projects looking at the environment of care, roles, processes and documentation. I also train staff in quality-improvement techniques, particularly around process redesign and change management.

My job is about working in partnership with patients and staff. It is also about developing partnerships with other agencies in the local health economy, bringing people together to find ways to make the patient's journey as smooth as possible.

One example of integrated care is in digestive diseases.

This has developed from a service split between seven different wards and departments into an integrated centre that focuses on patients' common needs rather than traditional notions of surgery and medicine.

What was your career path?

I trained as a registered general nurse at Hillingdon Hospital in the early 1980s. Then I was a staff nurse on medical and surgical wards before going to university in 1986. I spent five years studying industrial relations, economics and philosophy at Oxford and York. Out of term time I continued to work in just about every acute ward and department in West Middlesex University Hospital.

After leaving university I worked for four years at Age Concern England managing a national health promotion programme called Ageing Well - a partnership between statutory, voluntary and for-profit organisations. I was responsible for setting up pilot projects across the UK that involved trained older volunteers as senior health mentors for other older people. In 1995, the programme became the first national winner of the Department of Health's Healthy Alliance awards. Having discovered a knack for facilitation and project management, I returned to the NHS five years ago.

What attracted you to this job?

I was keen to work in an environment that focused on managing change rather than trying to manage for stability. It was a role that looked at service delivery from the perspective of the patient rather than the interests of any one professional group. The opportunity to work on a diverse range of projects was a big attraction. Also, the trust's commitment to staff development and the chance to live and work in Brighton were incentives.

How many people work in your team?

I manage four staff - three facilitators and an administrator. Because of the range of projects we are involved in, effective teamwork is essential for success.

However, I am also constantly aware of the risk of pigeonholing responsibility for change in any one part of an organisation. A lot of our work is therefore spent matrix-managing projects and persuading others to get involved.

How many hours a week do you work?

45 to 50 hours.

What is the most satisfying part of your work?

I get most satisfaction from piloting new ideas and getting projects started. I particularly enjoy facilitating groups of staff because I like the challenge of bringing together people with different views and agendas, and coming to a consensus to move things forward. The more challenging the group, the more I enjoy it.

Working in an organisation that is keen to try out new ideas is very important. For example, we have recently started to apply the theory of constraints approach to help improve patient throughput by identifying and managing bottlenecks.

What is the most frustrating thing about your job?

Getting frontline staff together to talk through problems is a constant frustration. Although staff have a lot of ideas, pressures on the service are so great that they cannot easily take time out to think about ways in which they could improve things.

Another frustration is the lack of understanding between different professional groups about roles and responsibilities. Some of this stems from the way training and education is set up.

What is the biggest challenge you face in the coming year?

The agenda for change in the NHS is so vast that the biggest challenge will be in prioritising key areas and staying focused on these. A major challenge will continue to be finding ways to meaningfully involve patients and carers in redesigning services.

How do you relax?

Walking on the South Downs.

What has been the high point of your career?

Receiving the national Healthy Alliance award - in so far as it was recognition for almost four years of project work. It was particularly rewarding because at that time building partnerships was often regarded as something of an add-on extra rather than something necessary for success.

If you had chosen an alternative career, what would it have been?

I would probably have chosen to be a philosophy lecturer.

My bedtime reading still tends to be anything on ethics and the philosophy of science.

Where do you see yourself in five years?

I hope to be working in a reinvigorated NHS, probably helping to develop more integrated services between health and social care and between prevention and cure.